Health inspection·May 13, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure three of 22 sampled residents (Resident 7, 9 and 13) were treated with dignity, when three Certified Nursing Assistants (CNA's) stood over residents while assisting with meals. These failures had the potential to violate Resident 7, 9 and 13's dignity while eating. Findings: During an observation on 5/10/21, at 11:53 a.m., in Resident 13's room, CNA 2 fed Resident 13 while standing. There was no chair in Resident 13's room, for CNA 2 to sit and feed Resident 13. During an observation on 5/10/21, at 12:04 p.m., in Resident 7's room, CNA 3 fed Resident 7 while standing. There was no chair in Resident 7's room, for CNA 3 to sit and feed Resident 7. During an observation on 5/10/21, at 12:16 p.m., in Resident 9's room, CNA 4 fed Resident 9 while standing. There was no chair in Resident 9's room for CNA 4 to sit and feed Resident 9. During an interview on 5/10/21, at 12:37 p.m., with CNA 2, CNA 2 stated she stood up to feed Resident 13 because the resident would move around a lot and she needed to make sure he sat still while feeding him. CNA 2 stated she needed to sit while feeding Resident 13 and speak with the resident to ensure he liked the food. CNA 2 stated she needed to sit while feeding Resident 13 to ensure he felt dignified while eating. During an interview on 5/10/21, at 12:43 p.m., with CNA 3, CNA 3 stated it was important to maintain residents' dignity when feeding them. CNA 3 stated sitting and talking to residents would ensure residents' dignity. During an interview on 5/10/21, at 12:48 p.m., with CNA 4, CNA 4 stated she stood up to feed Resident 9 because she felt more comfortable standing while feeding Resident 9. CNA 4 stated sitting in a chair while feeding residents could make them feel more comfortable and encourage residents to eat. During an interview on 5/13/21, at 9:22 a.m., with the Dietary Manager (DM), the DM stated CNA's should sit next to the residents when feeding them so the residents do not feel towered over and feel uncomfortable while eating. The DM stated it was important for CNA's to be at eye level with residents when feeding and provide residents their dignity while eating. During an interview on 5/13/21, at 9:26 a.m., with the Director of Nursing (DON), the DON stated Page 1 of 15 555347 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA's should have been sitting while feeding residents. The DON stated it was important for CNA's to be at eye level with the residents to make them feel comfortable while eating. The DON stated CNA's needed to make residents feel comfortable while eating to ensure the residents' dignity. During a review of Resident 7's admission Record (AR), dated 5/13/21, the AR indicated, .Original admission Date 6/1/2012 .Diagnosis Information .Parkinson's Disease (disorder of the central nervous system that affects movement, and loss of balance) . During a review of Resident 7's Minimum Data Set Section G Functional Status (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 3/17/21, the MDS, indicated, .Activities of Daily Living (ADL) Assistance .H. Eating-how resident eats and drinks .4. Total dependence-full staff performance every time . During a review of Resident 9's admission Record (AR), dated 5/13/21, the AR indicated, .Original admission Date 4/26/2017 .Diagnosis Information .Unspecified Dementia with Behavioral Disturbance (group of thinking and social symptoms that interfere with daily functioning) . During a review of Resident 9's MDS, dated 3/17/21, the MDS, indicated, .Activities of Daily Living (ADL) Assistance .H. Eating-how resident eats and drinks .4. Total dependence-full staff performance . During a review of Resident 13's admission Record (AR), dated 5/13/21, the AR indicated, .Original admission Date 7/22/2019 .Diagnosis Information .Parkinson's Disease .Degenerative Disease of Nervous system (diseases that affect body's activities such as balance, movement, talking, breathing and heart function) . During a review of Resident 13's MDS, dated 3/17/21, the MDS, indicated, .Activities of Daily Living (ADL) Assistance .H. Eating-how resident eats and drinks .4. Total dependence-full staff performance . During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, dated 1/18, the P&P indicated, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example a. Not standing over residents while assisting with meals . 555347 Page 2 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a comprehensive person focused care plan for one of 22 sampled residents (Resident 17) when Resident 17 was assessed to have hearing deficits and the facility did not develop a hearing deficits care plan. This failure placed Resident 17 at risk of not having his hearing needs met. Findings: During an observation on 5/10/21, at 12:35 p.m., in Resident 17's room, Resident 17 was in bed. Resident 17 was asked a question and she put her right hand next to her ear and leaned forward. Resident 17 was not able to respond to the question. During an interview on 5/10/21, at 12:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 17 was hard of hearing and did not have hearing aids. During a review of Resident 17's admission Record, dated 1/10/19, indicated, .Original admission Date 1/10/19 . During an interview on 5/12/21, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 17 had hearing problems. During a interview, on 5/13/21, at 10:48 a.m., with the Social Worker (SW), the SW stated the hearing care plan for Resident 17 should have been develop on 3/11/21, when Resident 17 was assessed by the Audiologist on 3/11/21 with a severe and profound hearing loss and needed a hearing aid. The SW stated It was my mistake [not inputting a hearing deficit care plan]. The SW stated the hearing care plan was important to ensure staff were able to communicate and provide appropriate care for Resident 17. During an interview on 5/13/21, at 11:48 a.m., with the Director of Nursing (DON), the DON stated the hearing care plan for Resident 17 should have been initiatied on 3/11/21. The DON stated the hearing care plan was important to ensure staff were able to communicate and provide appropriate care for Resident 17. During a review of the facility's policy and procedure titled, Care Plan, dated 1/2018, indicated, An individualized Comprehensive care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 4. Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Reflect treating goals and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status/or functional levels .5. The resident's Comprehensive Care Plan is developed within seven days of the completion of the resident's comprehensive assessment . 6. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly . 555347 Page 3 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to develop a comprehensive person focused care plan for one of 22 sampled residents (Resident 17) when Resident 17 was assessed to have hearing deficits and the facility did not develop a hearing deficits care plan. This failure placed Resident 17 at risk of not having his hearing needs met. Findings: During an observation on 5/10/21, at 12:35 p.m., in Resident 17's room, Resident 17 was in bed. Resident 17 was asked a question and she put her right hand next to her ear and leaned forward. Resident 17 was not able to respond to the question. During an interview on 5/10/21, at 12:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 17 was hard of hearing and did not have hearing aids. During a review of Resident 17's admission Record, dated 1/10/19, indicated, .Original admission Date 1/10/19 . During an interview on 5/12/21, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 17 had hearing problems. During a interview, on 5/13/21, at 10:48 a.m., with the Social Worker (SW), the SW stated the hearing care plan for Resident 17 should have been develop on 3/11/21, when Resident 17 was assessed by the Audiologist on 3/11/21 with a severe and profound hearing loss and needed a hearing aid. The SW stated It was my mistake [not inputting a hearing deficit care plan]. The SW stated the hearing care plan was important to ensure staff were able to communicate and provide appropriate care for Resident 17. During an interview on 5/13/21, at 11:48 a.m., with the Director of Nursing (DON), the DON stated the hearing care plan for Resident 17 should have been initiatied on 3/11/21. The DON stated the hearing care plan was important to ensure staff were able to communicate and provide appropriate care for Resident 17. During a review of the facility's policy and procedure titled, Care Plan, dated 1/2018, indicated, An individualized Comprehensive care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 4. Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Reflect treating goals and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status/or functional levels .5. The resident's Comprehensive Care Plan is developed within seven days of the completion of the resident's comprehensive assessment . 6. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly . 555347 Page 4 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure sanitary conditions and safe food handling were maintain in the kitchen for 22 of 22 sampled residents when: Residents Affected - Many 1. 12 food bowls and three cups were placed on top of one another and were stored moist; 2. One food bowl contained a white substance was stored with clean food bowls; 3. Five loaves of expired bread was stored in the kitchen; 4. A fan in the food preparation area had black substance present on the fan blades. These failures placed 22 residents at risk for foodborne illness (illness caused by contaminated food or water). Findings: 1. During a concurrent observation and interview, on 5/10/21, at 10 a.m., with the Cook, in the kitchen, 12 food bowls were stored and stacked (on top of one another) and were found moist in a dish rack. Three cups were stored moist in an aluminum tray. The [NAME] stated it was her responsibility to store the dishes clean and dry, and it was not done. During a concurrent interview and record review, on 5/10/21, at 3:16 p.m., with the Dietary Manager (DM), the policy and procedure (P&P) titled, Dish Washing, dated 2018, was reviewed. The P&P indicated, .Dishes are to be air dried in racks before stacking and storing . The DM stated the food bowls and cups should be stored clean and dry, to prevent bacterial growth. During an interview on 5/11/21, at 3:21 p.m., with the Registered Dietitian (RD), the RD stated dishes should not be stored moist and wet, dishes should be stored clean and dry, to prevent bacterial growth. 2. During a concurrent observation and interview, on 5/10/21, at 10 a.m., with the Cook, in the kitchen, one food bowl was stored with a white substance. The [NAME] stated the white substance on the bowl was cereal. During a concurrent interview and record review, on 5/10/21, at 3:16 p.m., with the DM, the P&P titled, Dish Washing, dated 2018, was reviewed. The P&P indicated, .All dishes will be properly sanitized through the dishwasher .Gross food particles shall be removed by carefully scraping and pre-rinsing in running water . The DM stated the food bowls and cups should be stored clean and dry, to prevent bacterial growth. During an interview on 5/11/21, at 3:21 p.m., with the RD, the RD stated dishes should be stored clean and dry, to prevent bacterial growth. 3. During a concurrent observation and interview, on 5/10/21, at 10 a.m., with the Cook, in the kitchen, there were five loaves of bread stored in the kitchen with a date that indicated the bread was opened on 4/29/21. The [NAME] stated the five loaves of bread should have been disposed of within 555347 Page 5 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0812 seven days from the open date. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 5/10/21, at 3:16 p.m., with DM, the P&P titled, Dry Goods Storage Guidelines was reviewed. The P&P indicated, .Food Item . Bread . Opened on shelf . 5-7 days . The DM stated the expired five loaves of bread should have been disposed and should not be stored in the kitchen. Residents Affected - Many During an interview on 5/11/21, at 3:21 p.m., with the RD, the RD stated expired food should be disposed, and should not be stored in the kitchen. The RD stated, We do not want the residents to get sick. 4. During a concurrent observation and interview, on 5/10/21, at 10 a.m., with the Cook, in the kitchen, the fan blades of a fan in the food preparation area had black residue present. During a concurrent interview and record review, on 5/10/21, at 3:16 p.m., with the DM, the P&P titled, Cleaning and Disinfection of Environment Surfaces dated 1/2018 was reviewed. The P&P indicated, .Environment surfaces will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC- national health agency which protects people from health threats) recommendations for disinfection of healthcare facilities . Environmental surfaces will be disinfected (or cleaned) on a regular basis . and when surfaces are visibly soiled . The DM stated the black residue on the fan blades were a mixture of grease and particles in the air. The DM stated the fan should have been cleaned. During an interview on 5/11/21, at 3:21 p.m., with the RD, the RD stated the fan blades in the food preparation area should be clean, to prevent dirty particles from going into the residents' food. 555347 Page 6 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to ensure the Weekly Nursing Notes (a medical record made by a nurse that provides an accurate reflection of nursing assessment and changes in patient conditions) accurately reflected residents' current hearing status for one of 22 sampled residents (Resident 17) when Resident 17's hearing loss was not accurately documented on the Weekly Nursing Notes. This failure had the potential for Resident 17's hearing needs to go unmet. Findings: During an observation on 5/12/21, at 12:35 p.m., in Resident 17's room, Resident 17 was in bed. Resident 17 was asked a question and put her right hand next to her ear and leaned forward. Resident 17 was not able to respond to the question. During an interview on 5/12/21, at 12:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 17 was hard of hearing and did not have hearing aids. During a review of Resident 17's admission Record, dated 1/10/19, indicated, .Original admission Date 1/10/19 . The admission Record did not have a diagnosis of hearing loss for Resident 17. During an interview on 5/12/21, at 1:35 p.m., with the Director of Nursing (DON), the DON stated Resident 17 had hearing problems. During a concurrent interview and record review on 5/12/21, at 1:46 p.m., with the Social Worker (SW), Resident 17's Audiological Assessment (a series of diagnostic procedures used to determine the type and degree of hearing loss), dated 3/11/21 was reviewed. The Audiological Assessment indicated, .2. Degree of hearing loss: Right .Severe to profound . Left . Severe to profound Hearing aid needed for resident's safety and ADL's (activities of daily living) . The SW stated Resident 17 did not have a hearing aid. The SW stated Resident 17 needed a hearing aid. During a concurrent observation and interview, on 5/12/21, at 2:03 p.m., with License Vocational Nurse (LVN) 1 in Resident 17's room, Resident 17 was in bed. LVN 1 called Resident 17 by her name and asked how she was doing. Resident 17 put her right hand next to her ear and leaned forward. Resident 17 was not able to respond to the question. LVN 1 stated Resident 17 was hard of hearing. During a concurrent interview and record review on 5/13/21, at 11:48 a.m., with the DON, Resident 17's Nursing Weekly Summary Notes (NWSN) dated 5/3/21 were reviewed. The NWSN indicated, . Ability to hear (with hearing aid or hearing appliance if normally used): Adequate . 11. Hearing aid or other hearing appliance used . No . The DON stated licensed nurse should ensure accuracy of assessments and documentation. During a review of the facility's policy and procedure titled, Charting and Documentation, dated 1/2018, indicated, All services provided to the resident, progress towards the care plan, goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communicate between the interdisciplinary team regarding the resident's condition and response to care . Documentation in the 555347 Page 7 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0842 medical record will be objective (not opinionated or speculative), complete, and accurate . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555347 Page 8 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to take actions aimed at performance improvement when an ice machine (water?) filter, oxygen concentrators (a medical device that provides oxygen to patients) and call light system were not maintained (maintenanced per manufactures guidelines? ). [Refer

F908, F919] These failures had the potential to result in physical harm to residents from foodborne illnesses, supplying inadequate oxygen levels, and having needs unmet by staff. Findings: During an interview on 5/13/21, at 1:46 p.m., with the Administrator (ADM), the ADM stated the facility was not aware of the water filter (is the ice machine filter the same as the water filter?) not being serviced for over a year. The ADM stated it was his responsibility to ensure the water filter was serviced to prevent the potential of contaminated ice. The ADM stated the residents in the facility used the ice in the ice machine. The ADM stated it was important to service the water filter for the ice machine to ensure no resident in the facility would get ill. The ADM stated the water filter for the ice machine was not part of improvement activities in the QAPI (quality assurance performance improvement-programs designed to improve quality of care and services delivered) plan. The ADM stated it was the responsibility of the Director of Nursing (DON) to maintain (maintain?? please clarify? DON does maintenance on O2 concentrators?) the oxygen concentrators per the manufacturer's recommendations. The ADM stated if oxygen concentrators were not working properly the residents could experience respiratory complications from not receiving adequate oxygenation. The ADM stated the call light system needed to be functioning for all residents to ensure they could alert staff for any care needs or emergency. The ADM stated it was important to have a schedule to routinely check all residents' call lights to ensure they were functioning properly. During a review of the facility policy and procedure (P&) titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 1/2018, the P&P indicated, .This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services .3. Provide structure and processes to correct identified quality and/or safety deficiencies 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome .6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility .1. The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI program. 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 1/2018, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of maintenance personnel includes . Providing routinely scheduled maintenance service to all areas . Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . (The ADM stated it was the DON who was responsible to maintain the O2 concentrators. Is the DON part of the Maintenance Department?) 555347 Page 9 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0867 Level of Harm - Minimal harm or potential for actual harm During a review of the ice machine General Maintenance Manufacture's Recommendation, dated 11/2018, indicated, .To insure economical, trouble free operation of your machine, it is recommended that following maintenance be performed every 6 months . Cleaning should be performed a minimum of every 6 months. Local water conditions may require that cleaning be performed more often . Check the water filter and replaced if dirty or restricted . Residents Affected - Many During a review of the facility job description titled, Administrator, dated 10/16/15, indicated, .The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents .12. Concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents. Also ensures that the Center adheres to legal, safety, health, fire and sanitation codes . During a review of the facility job description titled, Director of Nursing, dated 10/19/15, indicated, .1.7 Makes recommendations to the Administrator regarding nursing care equipment/supplies required to meet the needs of the patients and assures that adequate supplies are available . 555347 Page 10 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure patient care equipment was maintained in safe operating conditions and in accordance to manufacturer's recommendations when: Residents Affected - Many 1. Two of two (Resident 4's and Resident 21's) oxygen concentrators (a medical device that provides oxygen to patients) did not receive recommended scheduled services per manufacturers' recommendations. This failure had the potential for Resident 4 and Resident 21 to not receive oxygen flow per physician's order and experience serious complications from the lack of oxygen. 2. One of one ice machine water filter was not checked for cleanliness and was not replaced per the manufacture's recommendation. This failure had the potential for residents in the facility to experience foodborne illness (illness caused by contaminated food or water) from contaminated ice. Findings: 1. During an observation on 5/10/21, at 12:05 p.m., in Resident 21's room, Resident 21 was in bed with his oxygen concentrator set at 2 liters per minute (unit of measurement). The oxygen concentrator had a label present that indicated a maintenance service date of 10/24/2019. During a review of Resident 21's admission Record (documents that gives a resident's information), dated 3/20/18, the admission Record indicated, .Diagnosis Information .Heart Failure (a condition in which the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen) . During a review of Resident 21's Order Summary, dated 11/23/20, the Order Summary indicated, .Administer oxygen at 2 liters per minute . During an observation on 5/10/21, at 2:37 p.m., in Resident 4's room, Resident 4 was in bed with her eyes closed. Resident 4's oxygen concentrator was set at 2 liters per minute. The oxygen concentrator had a label present that indicated a maintenance service date of 10/24/2019. During a review of Resident 4's admission Record, dated 11/24/20, the admission Record indicated, .Diagnosis Information .Heart Failure . During a review of Resident 4's Order Summary, dated 11/25/20, the Order Summary indicated, .Administer oxygen at 2 liters per minute . During an interview on 5/11/21, at 10:31 a.m., with the Facility Maintenance Director (FMD), the FMD stated the company which provides scheduled service maintenance to the oxygen concentrator had not come to the facility. The FMD stated he did not know when was the last time the oxygen concentrators were serviced. During an interview on 5/13/21, at 1:46 p.m., with the Administrator (ADM), the ADM stated it was 555347 Page 11 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0908 Level of Harm - Minimal harm or potential for actual harm the Director of Nursing's (DON) responsibility to maintain the oxygen concentrators on a yearly basis. The ADM stated oxygen concentrators preventative maintenance (maintenance that is regularly performed on a piece of equipment to lessen the likelihood of it failing) should be performed per manufacturer's recommendations to prevent serious complications to residents such as not receiving adequate oxygenation. Residents Affected - Many During an interview on 5/11/21, at 3:37 p.m., with the DON, the DON stated the oxygen concentrator should be serviced every six months per manufacturer's recommendations to make sure the oxygen concentrators functioned properly. The DON stated Resident 4 and Resident 21 could have respiratory problems if the oxygen concentrators were not functioning properly. During a review of the oxygen concentrator's guide titled, Routine Maintenance, undated, the guide indicated, Preventative Maintenance Record . every 8,760 hours [yearly], during preventative maintenance schedule, or between patients; Clean/Replace Cabinet Filters, Check outlet HEPA Filter [High Efficiency Particulate Absorbing], Check Compressor Inlet Filter, Check oxygen Concentrator, Check power loss alarm . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 1/2018, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of maintenance personnel includes . Providing routinely scheduled maintenance service to all areas . Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . 2. During a concurrent observation and interview, on 5/10/21, at 3:48 p.m., with the FMD, in the hallway near the ice machine, the ice machine water filter was dated 9/27/19. The FMD stated he had not checked the ice machine water filter for cleanliness. The FMD stated the ice machine water filter should have been changed to prevent water contaminants entering the ice machine. During an interview on 5/13/21, at 1:46 p.m., with the ADM, the ADM stated the facility was not aware of the water filter not being serviced for over a year. The ADM stated it was his responsibility to ensure the water filter was serviced to prevent the potential of contaminated ice. The ADM stated the residents in the facility were the ones who used the ice in the ice machine. The ADM stated it was important to service the water filter for the ice machine to ensure no residents in the facility would get ill. During a review of the facility job description titled, Administrator, dated 10/16/15, the job description indicated, .The Administrator is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to residents .12. Concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents. Also ensures that the Center adheres to legal, safety, health, fire and sanitation codes . During a review of the facility's P&P titled, Maintenance Service, dated 1/2018, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of maintenance personnel includes . Providing routinely 555347 Page 12 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many scheduled maintenance service to all areas . Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . During a review of the ice machine's guide titled, General Maintenance Manufacture's Recommendation, dated 11/2018, the guide indicated, .To insure economical, trouble free operation of your machine, it is recommended that following maintenance be performed every 6 months . Cleaning should be performed a minimum of every 6 months. Local water conditions may require that cleaning be performed more often . Check the water filter and replaced if dirty or restricted . 555347 Page 13 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation during the survey period of 5/10/21 to 5/13/21, the facility failed to provide and maintain a minimum of at least 80 square feet per resident in multiple resident rooms. Residents Affected - Some This failure has the potential for residents to not have reasonable privacy or adequate living space. Findings: During an observation on 5/10/21, the following rooms did not provide the minimum square footage in Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16. The residents had a reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room space for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend room waiver. __________________________________ Health Facilities Evaluator Supervisor Signature & Date ________________________________ Administrator Signature & Date 555347 Page 14 of 15 555347 05/13/2021 North Starr Postacute Care 180 Starr Avenue Turlock, CA 95380

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure call lights were working to provide a functioning communication system in which resident calls were received and answered for one of 22 sampled residents (Resident 4), when Resident 4's call light was not functioning. Residents Affected - Few This failure had the potential to result in Resident 4 to not receive help when in need, or in the event of an emergency. Findings: During an observation on 5/10/21, at 2:40 p.m., in Resident 4's room, Resident 4 was in bed with her eyes closed. Resident 4's call light cover was broken, and the call light was not functioning. During a review of Resident 4's admission Record (document that gives a patient's information), dated 11/24/20, the admission Record indicated, .Original admission Date 11/24/20 . During a review of Resident 4's Minimum Data Set (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs) assessment Section G (functional status), dated 3/3/21, the MDS Section G indicated, .A. Bed Mobility .4. Total dependence-full staff performance every time during entire 7-day period .I. Toilet use .4. Total dependence-full staff performance every time during entire 7-day period . During an interview on 5/10/21, at 2:43 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 4's call light was broken and not functioning on 5/7/21. CNA 1 stated she forgot to notify maintenance and write on the maintenance log book for repairs. CNA 1 stated the call light was important for Resident 4 to request assistance from staff. During an interview on 5/10/21, at 2:49 p.m., with the Facility Maintenance Director (FMD), the FMD stated facility staff should have notified him of Resident 4's broken call light. The FMD stated the broken call light was not documented in the maintenance log for repairs. The FMD stated the call light was important for Resident 4 to request assistance from staff and should have been fixed right away. During an interview on 5/11/21, at 3:37 p.m., with the Director of Nursing (DON), the DON stated Resident 4's call light should have been functioning properly for resident safety. The DON stated Resident 4 would not be able to request assistance from staff with the call light not functioning. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 1/2017, the P&P indicated, The purpose of this procedure is to respond to the resident's request and needs . Report all defective call lights to the nurse supervisor promptly . During a review of the facility's P&P titled, Maintenance Service, dated 1/2018, the P&P indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of maintenance personnel includes . Providing routinely scheduled maintenance service to all areas . 555347 Page 15 of 15